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Empowerment, Cooperation Guide TRICARE Success

By Douglas J. Gillert
American Forces Press Service

SAN DIEGO, June 8, 1999 – Dr. [Rear Adm.] Alberto Diaz inherited a tight ship -- a well-oiled and working TRICARE program that often serves as a beacon for less mature programs across the nation. And, as any smart captain of a ship under sail in smooth waters, he does everything he can to keep the boat from rocking.

Like any ship captain, Diaz relies on an able crew, which he has, he said. And on a simple leadership concept: empowerment.

"We empower our people," the senior medical officer, or lead agent, for TRICARE Southern California said. "In return, we get a lot of creative ideas and 'out-of-the-box' thinking. We also let everyone know it's OK to make mistakes. If you try something and it doesn't work, you learn from that, too."

So there's a real attitude of "let's try this and see if it works," agreed Navy Capt. Kristine Minnick, Diaz's "first mate" as director of TRICARE Southern California operations. She credited Dr. [Vice Adm.] Richard Nelson, Diaz's predecessor and now the Navy surgeon general, with charting the initial course.

"Admiral Nelson's mandate was 'We're in this together,'" Minnick said. And that means all the components of TRICARE -- lead agent's office, treatment facilities, prime contractor and the civilian provider network -- have to work in unison, she said.

And they do. "Coordination and cooperation here is legend in TRICARE," Minnick said. Every component shares in the decision process, with the managed care support contractor, Foundation Health Federal Service Inc., having a vote on every steering committee and council. Collectively, TRICARE Southern California components have forged a plan that puts quality health care delivery at a premium by improving access to care, controlling costs and emphasizing patient satisfaction.

"Quality of health care never was an issue. It was always here. But access became an issue because of downsizing here and throughout DoD," she said. Forced to reduce staff and close or cut clinical services, the defense medical department was no longer able to deliver the same level of care everywhere. "TRICARE evens out the benefit," Minnick said.

To improve access and at the same time keep costs down, TRICARE Southern California set about achieving maximum enrollment in the plan's managed care benefit, TRICARE Prime, within military medical facilities. Fully 73 percent of beneficiaries eligible for care at the San Diego Naval Medical Center get their Prime care there, she said. The others receive care through a supplemental network of civilian physicians who fall under the managed care support contract held by Foundation.

The numbers slant more toward Foundation in Los Angeles, where military facilities are limited and long drive times make it easier to get to a civilian doctor, she said. Foundation covers the region with a robust network of 4,900 primary care physicians and 11,000 specialists, she said.

Satisfaction surveys supposedly mirror accessibility and paint a rosy picture in Southern California, Minnick said. The region also examines access issues with a computer database "to make sure," however.

A major area of concern, she said, is service members assigned to remote areas. A Prime remote benefit being tested in TRICARE Northwest (Washington, Oregon and Idaho) will be exported to Southern California in fiscal 2000 and should solve any problems, Minnick said.

"It's the kind of program we want across the country, so our active duty enrollees have the same benefit no matter where they're assigned," she said.

Although quality care has always been a reality here, according to Diaz, Minnick and others, TRICARE Southern California continues to explore new, innovative methods of health care delivery. In the area of disease management, for example, a telemedicine initiative that delivers home health care to pediatric asthma patients has decreased emergency room visits and provided higher satisfaction among both patients and physicians.

Foundation proposed and engineered the pediatric asthma plan that Peter McLaughlin, vice president for TRICARE operations in California, said could be adapted for other diseases and Minnick called a model of performance for other TRICARE programs.

One thing the TRICARE leaders here didn't want to do was hamper quality with necessary cost-cutting programs. So far, they've had good success in meeting Military Health System cost constraints, Minnick said. Rolling more care into existing military medical facilities has saved the region more than $62 million, based on estimates using cost data under the old CHAMPUS program.

To further enhance use of the military facilities, the lead agent and Foundation established a resource-sharing program, whereby Foundation places medical staff, equipment and supplies inside military facilities, saving overhead costs.

"The Defense Department spends $900 million a year for delivery of the entire health plan in this region," said Navy Lt. Richard Haupt, public affairs officer for TRICARE Southern California. "About two-thirds of that care is delivered inside military facilities, and we've built incentives into the Foundation contract to optimize military treatment facility utilization, because the infrastructure is already there."

TRICARE Southern California has 78 resource-sharing agreements in effect, with dozens more in the pipeline, McLaughlin said.

The next gauge of the region's ability to keep costs down and satisfaction up will come next year, when the region undergoes a careful scrutiny by CNA Corp. and the Institute for Defense Analyses. The Military Health System's annual report to Congress reflected what the analyses found in TRICARE Northwest and will look at in Southern California and eventually all regions, Minnick said. "It's a critical document," she said, that showed in the northwest that TRICARE is delivering on its promises to maintain quality care and maintain or reduce costs.

But the game isn't over. "We haven't finished with TRICARE, yet," Diaz said. "For example, folks back east aren't as familiar with managed care as those on the West Coast. We have to better market that everywhere, and not just to our patients but to our providers, especially new ones coming into the program." Diaz said the system also needs must become more uniform across the country, improve enrollment ease and become more transportable from region to region. "All these issues are being addressed but will take time," he said.

In the wave of negative publicity about managed care in general, Diaz contends that TRICARE is different.

"We're not only providing better medical care, but we're managing your care over managing health prices," he said. "The upside of that is that care comes first, but at the same time we're keeping costs down."

Diaz also said requiring patients to go through a primary care manager doesn't hinder quality care. "When you go see a primary care manager, you're seeing a generalist who focuses on your whole health and can give you better overall treatment," he said. "As an example, more cases of depression are handled by primary care managers than by mental health practitioners."

TRICARE operations' McLaughlin, who said he knows the ins and outs of just about every health care plan available, echoed Diaz's sentiments. "TRICARE has probably the best benefit structure of any health plan in the country," he said.

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